Eligibility
Period of Coverage
Description of Benefits
Covered Expenses
Policy Maximums
Deductible Choices
Co-insurance
Additional Benefits
Definitions
Exclusions
Accidental Death & Dismemberment Benefits
Accidental Death & Dismemberment Exclusions
Optional Benefits
ELIGIBILITY
This coverage is only available to persons traveling to the United States. Coverage for travel outside the United States is available through the Diplomat
International. Coverage for up to 36 months is available through the Diplomat LT. Coverage can be obtained for groups of 5 or more. Brochures and rates on these plans are available from your
agent.
Diplomat America provides Accident and Sickness medical coverage, Accidental Death and Dismemberment benefits and Travel Assistance to individuals while traveling
to the United States for fifteen days to twelve months. Coverage is available to you, your spouse, and any unmarried dependent children ages 14 days up to 18 years.
This brochure is a brief description of the benefits of the Diplomat America program. A complete description is contained in the Description of Coverage, which will
be mailed to you upon your enrollment in the program. Coverage can only begin when the correct premium and a complete application are received by Global Underwriters, Inc. Please keep a copy of
this brochure for reference.
[Back to Top]
PERIOD OF COVERAGE
The minimum period of coverage that can be purchased under this plan is fifteen days and the maximum period of coverage is twelve months. Coverage can be purchased in fifteen day and/or monthly
increments. You can also combine these increments to suit your travel needs.
EFFECTIVE DATE
Coverage will begin on the later of the following:
a) Your departure from your Home Country ; or
b) The date your complete application and correct premium are received by Global Underwriters Agency ; or
c) The effective date requested on the application.
EXPIRATION DATE
Coverage will end on the earlier of the following:
a) Your return to your Home Country; or
b) Twelve months after your coverage’s effective date; or
c) The termination date shown on the certificate, for which premium has been paid.
Excess Benefits - All Coverage, except Accidental Death & Dismemberment, shall be in excess of all other valid and collectible insurance.
Refund of premium, less a $25 processing fee, will be considered only if written request is received by Global Underwriters prior to the effective date of coverage. After that date, the premium
is considered fully earned and non-refundable. Partial refunds are not available.
[Back to Top]
Description of Benefits
All coverage, benefits and premiums are in U.S. Dollar amounts. If an Injury or Illness occurs in the USA during the Period of Coverage and the Insured Person requires medical or surgical
treatment; this plan will pay, subject to the selected deductible and co-insurance, the following Covered Expenses, up to the selected policy maximum. Benefits payable under this plan may not be
assigned.
[Back to Top]
Covered Expenses
Only such expenses incurred as the result of and within 52 weeks from a disablement, and which are and which specifically enumerated in the following list of charges: 1) Charges made by a
hospital for room and board, floor nursing and other services, including charges for professional services, except personal services of a non-medical nature, provided, however, that expenses do
not exceed the hospital's average charge for semi-private room and board accommodation, or three (3) times the average semi-private room charge if confinement to an intensive care unit is
required, or the actual charge for an intensive care unit made by the servicing hospital, whichever is less; 2) Charges made for diagnosis, treatment and surgery by a Physician; 3) Charges made
for the cost and administration of anesthetics; 4) Charges for medication, x-ray services, laboratory tests and services, the use of radium and radio-active isotopes, oxygen, blood transfusions,
iron lungs, and medical treatment; 5) Charges for physiotherapy, if recommended by a Physician for the treatment of a specific disablement and administered by a licensed physiotherapist; 6)
Hotel room charge, when the insured, otherwise necessarily confined in a hospital, shall be under the care of a duly qualified Physician in a hotel room owing to the unavailability of a hospital
room by reason of capacity or distance or to any other circumstances beyond the control of the insured; 7) Dressings, drugs, and medicines that can only be obtained upon written prescription of
a Physician or surgeon. With regard to chiropractic care, if recommended by a Physician for the treatment of a specific disablement and administered by a licensed chiropractor, 80% of eligible
charges up to $35.00 per visit, with a maximum of 10 visits per injury or illness is allowable.
[Back to Top]
Policy Maximum Choices
Plan A - $ 50,000, Plan B - $ 100,000, Plan C - $ 250,000, Plan D - $ 500,000
Persons up to age 59 are eligible for all plans; Persons age 60-69 are eligible for plans A, B, and C; Persons age 70+ are eligible for Plan A only.
[Back to Top]
Deductible Choices
$100, $250, $500, $1,000, $2,500 per person per policy period.
[Back to Top]
Co-insurance
After you pay your selected deductible this plan will pay: 80% of covered expenses up to $5,000 and 100% thereafter up to the selected policy maximum. Eligible expenses are based on Usual,
Customary & Reasonable charges (UCR).
[Back to Top]
Emergency Medical Evacuation
The Company will pay benefits for Covered Expenses incurred for the necessary emergency medical evacuation of an Insured Person up to a $100,000 maximum. Emergency Medical Evacuation means: a)
the Insured Person’s medical condition warrants immediate transportation from the place where the Insured Person is injured or ill, to the nearest hospital where appropriate medical treatment
can be obtained; or b) after being treated at a local hospital, the Insured Person’s medical condition warrants transportation to their Home Country to obtain further medical treatment or to
recover. Covered expenses are expenses for the transportation, medical services and supplies recommended by the attending Physician and necessarily incurred, in connection with an Insured
Person’s emergency medical evacuation. All transportation for an Insured Person’s emergency medical evacuation must be arranged by AIG Assist utilizing the most direct and economical
conveyance. Covered expenses for transportation which include but are not limited to air, water or land ambulance, and private motor vehicle, must be: a) recommended by the attending Physician;
or b) required by the standard regulations of the conveyance transporting the Insured Person.
Emergency Reunion
In the event of an Emergency Medical Evacuation due to a covered injury or illness, where the physician feels that it would be beneficial for the Insured to have a family member at their side
during transport, the Company will reimburse the Insured for travel and lodging expenses, up to a maximum of $10,000.00. AIG Assist must make all arrangements and must authorize all expenses in
advance. The Company reserves the right to determine the benefit payable, including reductions, if it is not reasonably possible to contact AIG Assist in advance.
Repatriation of Remains Expenses
If injury or illness commencing during the period of coverage results in death, all reasonable expenses incurred for preparation and return of the remains to your Home Country or Country of
Residence, are covered up to a maximum of $20,000, must be arranged by AIG Assist utilizing the most direct and economical conveyance.
Definitions
The term “Home Country” shall mean, the country where an eligible person(s) has his/her fixed and permanent home establishment and to which he/she has the intention of returning. The term
“Hospital” shall mean, a facility that: (1) is operated according to law for the care and treatment of injured people; (2) has organized facilities for diagnosis and surgery on its premises
or in facilities available to it on a prearranged basis; (3) has 24hour nursing service by registered nurses (R.N.’s); and (4) is supervised by one or more Physicians. A Hospital does not
include: (1)a nursing, convalescent or geriatric unit of a hospital when a patient is confined mainly to receive nursing care; (2) a facility that is, other than incidentally, a rest home,
nursing home, convalescent home or home for the aged; nor does it include any ward, room, wing, or other section of the hospital that is used for such purposes; or (3) any military or veterans
hospital or soldiers home or any hospital contracted for or operated by any national government or government agency for the treatment of members or exmembers of the armed forces. The term
“Illness” shall mean, sickness or disease of any kind contracted and commencing after the effective date of coverage for an Insured Person; and causing loss covered by this Plan. The term
“Injury” shall mean, bodily injury caused solely and directly by violent, accidental, external, and visible means occurring while the Policy is in force; and resulting directly and
independently of all other causes of loss covered by this Plan. The term “Physician” shall mean, a licensed practitioner of the healing arts acting within the scope of his or her license who
is not: (1) the Insured; (2) an Immediate Family Member; or (3) retained by the Policyholder. Such definition will exclude chiropractors and physiotherapists. In the event services are provided
by chiropractors or physiotherapists these healthcare professionals must be licensed and acting within the scope of their license and may not be (1) the Insured; (2) an Immediate Family Member;
or (3) retained by the Policyholder. The term “Immediate Family Member” means a person who is related to the Insured in any of the following ways: spouse, brother-in-law, sister-in-law,
daughter-in-law, mother-in-law, father-in-law, parent (includes stepparent), brother or sister (includes stepbrother or stepsister), or child (includes legally adopted or stepchild). The term
“Pre Existing Condition” means any injury or illness which was contracted or which manifested itself, or for which treatment or medication was prescribed three (3) years prior to the
effective date of this insurance.
[Back to Top]
Exclusions
For the Medical Expense, Emergency Medical Evacuation and Repatriation of Remains benefits, no benefit shall be payable with respect to expenses incurred:
1. PRE-EXISTING CONDITIONS, For Pre-Existing Conditions, defined as any injury or illness which was contracted or which manifested itself, or for which treatment or medication was
prescribed 3 years prior to the effective date of this insurance; 2. For services, supplies, or treatment; including any period of hospital confinement, which were not recommended, approved and
certified as necessary and reasonable by a physician; 3. For suicide or any attempt thereat while sane or self-destruction or any attempt thereat while insane; 4. Declared or undeclared war; or
any act thereof; 5. For injury sustained while participating in professional athletics; 6. For sickness resulting from pregnancy, childbirth, or miscarriage; 7. For miscarriage resulting from an
accident; 8. For routine physicals or other examinations where there are no objective indications or impairment in normal health, and laboratory diagnostic or x-ray examinations except in the
course of a disability established by the prior call or attendance of a physician; 9. For cosmetic or plastic surgery; except as the result of an accident; 10.For elective surgery which can be
postponed until the insured returns to his/her country of residence; 11. For any mental or nervous disorders or rest cures; 12. For dental care; except as the result of Injury to natural teeth
caused by an accident;
13. For eye refractions or eye examinations for the purpose of prescribing corrective lenses or for the fitting thereof; unless caused by accidental bodily injury incurred while insured
hereunder; 14.In connection with alcoholism or drug addiction; or the use of any drug or narcotic agent; 15. For congenital anomalies and conditions arising out of or resulting therefrom; 16.
For expenses which are non-medical in nature; 17. For the ordinary cost of a one-way airplane ticket used in the transportation back to the insured’s country where an air ambulance benefit is
provided; 18. For expenses as a result of or in connection intentionally self-inflicted injury; 19. For expenses as a result of or in connection with the commission of a felony offense; 20. For
specific named hazards: motorcycle driving, scuba diving, skiing, mountain climbing, sky diving, professional or amateur racing, and piloting any aircraft;
21. Treatment paid for or furnished under any other individual or group policy, or other service or medical pre-payment plan arranged through the employer to the extent so furnished or paid, or
under any mandatory government program or facility set up for treatment without cost to any individual;
[Back to Top]
Accidental Death and Dismemberment
The amount of the Principal Sum is $25,000
Description of Loss/Indemnity
Life /Principal Sum
Both Hands or Both Feet or Sight of Both Eyes/Principal Sum
One Hand and One Foot/Principal Sum
Either Hand or Foot and Sight of One Eye/One-half the Principal Sum
Either Hand or Foot/One-Half the Principal Sum
Sight of One Eye/One-Half the Principal Sum
The term “loss” as used herein shall mean, with regard to hands and feet, actual severance through or above wrist or ankle joint, and with regard to eyes, entire irrecoverable loss of sight.
Paralysis Benefit
If Injury to the Insured results, within 365 days of the date of the accident that caused the Injury, in any one of the types of paralysis specified below, the Company will pay the percentage of
the Maximum Amount shown below for that type of paralysis:
| Type of Paralysis |
Percentage of the $25,000 Principal Sum |
| Quadriplegia |
100% |
| Paraplegia |
75% |
| Hemiplegia |
50% |
| Uniplegia |
25% |
“Quadriplegia” means the complete and irreversible paralysis of both upper and both lower limbs. “Paraplegia” means the complete and irreversible paralysis of both lower limbs.
“Hemiplegia” means the complete and irreversible paralysis of the upper and lower limbs of the same side of the body. “Uniplegia” means the complete and irreversible paralysis of one
limb. “Limb” means entire arm or entire leg.
If the Insured suffers more than one type of paralysis as a result of the same accident, only one amount, the largest, will be paid.
Only such expenses incurred as the result of and within the Benefit Period of a disablement, which are specifically included in the above list of charges, which are incurred outside the
Insured Person's home country or country of residence and which are not excluded by the provisions of this plan shall be considered covered expenses.
[Back to Top]
Accidental Death and Dismemberment Exclusions
For Accidental Death and Dismemberment Indemnity this plan does not cover any loss caused by or resulting from:
1. For suicide or any attempt thereat by the Insured Person while sane or self-destruction or any attempt thereat by the Insured Person while insane;
2. disease of any kind
3. bacterial infections except pyogenic infection which shall occur through an accidental cut or wound;
4. hernia of any kind
5. Injury sustained in consequence of riding as a passenger or otherwise in any vehicle or device for aerial navigation;
6. declared or undeclared war or any act thereof;
7. Service in the military, naval, or air service of any country.
[Back to Top]
OPTIONAL RIDERS
Hazardous Activity Coverage - motorcycling, scuba diving, jet, snow, and water skiing, mountain climbing, sky diving, amateur racing, piloting any aircraft, bungee jumping, spelunking,
whitewater rafting, surfing, and parasailing coverage.
Athletic Coverage - for participation in amateur, club, intramural, interscholastic or intercollegiate tennis, swimming, cross country, track, baseball, softball, volleyball and golf sports
only. All other sports are excluded.
[Back to Top]
|